community-based first aid - laurentian university · 3 community-based first aid: ... and the red...

VanderBurgh D et al 1

1 2

Community-Based First Aid: 3 A Program Report on the Intersection of Community-Based Participatory Research and 4

First Aid Education in a Remote Canadian Aboriginal Community 5 6

First published in the journal, Rural and Remote Health [http://www.rrh.org.au] 7 8 Re-submitted to Rural and Remote Health June 2013. 9 Section: Project Report, North America. 10 11 Word Count 3034 12 Total Figures (2) – Box 1. Sachigo Lake First Nation 13

Box 2. Lessons Learned 14 15 David VanderBurgh MD CCFP(EM)* (Corresponding author) 16 Assistant Professor, Division of Clinical Sciences 17 Northern Ontario School of Medicine 18 c/o Thunder Bay Regional Health Sciences Centre 19 980 Oliver Rd. 20 Thunder Bay, ON Canada P7B 6V4 21 Phone 807 620 1206 22 Fax 1 800 466 0567 23 email [email protected] 24 25 Rachel Jamieson PCP 26 Primary Care Paramedic, Alberta Health Services - Calgary Metro EMS 27 Calgary, AB Canada 28 email [email protected] 29 30 Jackson Beardy 31 Health Services 32 Sachigo Lake First Nation 33 PO Box 51 34 Sachigo Lake, ON Canada P0V 2P0 35 email [email protected] 36 37 Stephen D Ritchie BPE MBA PhD (Candidate) 38 School of Rural and Northern Health; ECHO (Evaluating Children’s Health Outcomes) Research 39 Centre 40 Laurentian University 41 Ramsey Lake Road 42 Sudbury, ON Canada P3E 2C6 43 email [email protected] 44 45 Aaron Orkin MD MSc MPH CCFP 46 Assistant Professor, Division of Clinical Sciences 47 Northern Ontario School of Medicine 48 955 Oliver Road 49 Thunder Bay, ON Canada P7B 5E1 50 email [email protected] 51 52 53


1 2 Funding. This project was funded by grants from the Canadian Institutes of Health Research and 3 the Northern Ontario Academic Medical Association (NOAMA; http://www.noama.ca). The 4 funder had no role in study design, data collection and analysis, decision to publish, or 5 preparation of the manuscript. 6 7 Competing Interests Statement. DV, RJ, AO have worked with Wilderness Medical Associates 8 International, a wilderness medicine education organization. This organization was not involved in 9 any part of the research submitted as part of this manuscript. Other authors have no competing 10 interests to declare.11


Abstract 1 Context. Community-based first aid training is the collaborative development of locally 2 relevant emergency response training. The Sachigo Lake Wilderness Emergency 3 Response Education Initiative was developed, delivered, and evaluated through two 4 intensive five-day first aid courses. Sachigo Lake First Nation is a remote aboriginal 5 community of 450 people in northern Ontario, Canada with no local paramedical 6 services. These courses were developed in collaboration with the community, with a 7 goal of building community capacity to respond to medical emergencies. 8 Issue. Most first aid training programs rely on standardized curriculum developed for 9 urban & rural contexts with established emergency response systems. Delivering 10 effective community-based first aid training in remote aboriginal communities required 11 specific adaptations to conventional first aid educational content and pedagogy. 12 Lessons Learned. Three key lessons emerged during this program that used 13 collaborative principles to adapt conventional first aid concepts and curriculum. (1) 14 Standard algorithmic approaches may not be relevant nor appropriate. (2) Relationships 15 between course participants and the people they help are relevant and important. (3) 16 Curriculum must be attentive to existing informal and formal emergency response 17 systems. These lessons may be instructive for the development of other programs in 18 similar settings. 19 20 21

Context 22

23

This paper considers the intersection of conventional first aid education and the remote 24

fly-in aboriginal community of Sachigo Lake First Nation in sub-Arctic Canada (see Box 25

1). This intersection highlighted incompatibilities between standard first aid and local 26

community needs. These were addressed through a community-based collaboration 27

and the development of a unique, community-specific first aid program. 28

29

Over the past three years, through a process of community consultation and 30

collaboration, the Sachigo Lake Wilderness Emergency Response Education Initiative 31

(SLWEREI) was developed, delivered and evaluated. This unique community-based 32

first aid program involved two intensive five-day first aid training courses for lay 33

community members held in 2010 and 2012. Through two courses, the program has 34

trained 26 adults, approximately 5 percent of the community population. 35

36

Training centred on providing essential life-support in emergency situations, with a focus 37

on patient transport and the provision of adaptive care in low-resource and wilderness 38

settings. Course curriculum and pedagogy were based on community priorities, needs 39

and feedback received through community consultation. 40

41


Community consultation was both formal and informal involving an initial 3 day site visit 1

and needs assessment, formal interviews with key stakeholders focused on curriculum 2

and pedagogy, survey feedback from course participants, and conversations with 3

community members over the telephone and during the weeks we have spent in 4

Sachigo Lake First Nation over the last three years. 5

6

Curriculum covered topics ranging from basic trauma care and cardiopulmonary 7

resuscitation to mental health first aid, diabetic emergencies, and safe patient transport. 8

The courses spent little time in a classroom setting with the majority of learning focused 9

on practical skills training and simulation with debrief. The SLWEREI was based on a 10

simple premise, buttressed by World Health Organization and American Heart 11

Association guidelines: in underserviced settings, first response education may enhance 12

community resilience and capacity to manage emergencies and save lives[1,2]. 13

14

The purpose of this paper is not to present the research details or outcomes of this 15

initiative; these have been described elsewhere[3,4]. Rather, this paper reports on 16

curricular and pedagogical lessons learned as our team developed a unique first aid 17

training program. The specific adaptations to first aid educational content and 18

methodology required to deliver effective community-based training in remote aboriginal 19

communities has not been described elsewhere. 20

21 Issue: Standard First Aid and Community-Based First Aid 22

23

First Aid is ‘the assessment and interventions that can be performed by a bystander (or 24

by the victim) with minimal or no medical equipment[2].’ First aid emerged from a 25

paramilitary tradition, rooted in the International Red Cross[5]. In North America, 26

organizations such as the Amercian Heart Association (AHA), National Life Saving 27

Box 1. Sachigo Lake First NationSachigo Lake First Nation is a remote aboriginal community of 450 people in northern Ontario, Canada with no local paramedical services. The community is accessible by plane throughout the year, and by seasonal ice road for several weeks during the winter. Full-time nursing staff provides services at a local nursing station. A family physician visits the community for 2–3 days per month. To get to the Nursing Station, patients may be transported by snow machine, ATV, boat or truck. Hospital care is provided hundreds of kilometres away in Sioux Lookout, with transport times rarely less than 4 hours. Patients are transported to hospital by air ambulance.


Society, and the Red Cross outline the scope and principles of conventional first aid 1

education. 2

3

As a field of clinical practice, First Aid arises from a tradition of algorithmic guidelines, 4

universal practice standards, strictly delineated levels of certification and scopes of 5

practice, and a normative and a fundamentally positivistic approach to health and 6

physiology. The notion that health emergencies are adequately similar across cultures 7

and geographies forms a central premise of “standard first aid”, permitting a universal 8

and algorithmic bystander response and educational model. Clinical protocols and first 9

aid practice have been rooted in the simplification of diagnostic, therapeutic, and 10

transport decisions for sick patients, coupled with a drive to provide simple and universal 11

approaches to emergencies through basic training for non-clinicians. This model for 12

immediate and on-scene clinical care and transportation has proven tremendously 13

successful across a variety of settings from the battlefield to shopping centers, and first 14

aid training programs have been recognized internationally as an essential form of 15

health protection and promotion[6]. Non-conventional first aid programs have been 16

successful at improving outcomes in low-resource contexts with minimal paramedical 17

services in places such Ghana, Northern Iraq, Cambodia and Uganda[7,8,9,10]. 18

19

Over a period of years, our team has worked with Sachigo Lake First Nation to analyze 20

the pedagogy and curriucula of conventional courses. Through this partnership, we 21

customized a first aid training curriculum specifically suited to Sachigo Lake First Nation. 22

Our collaborative approach revealed incompatibilities between standard first aid and the 23

lived experience and needs of the Sachigo Lake community. Our customized first aid 24

program and experience captures several lessons learned that we now identify as 25

central to first response capacity-building and first aid programs in remote settings. 26

Together, these core concepts describe what we call “community-based first aid” 27

(CBFA), a community-oriented approach to first aid education. 28

29

Lessons Learned 30

We distilled several concepts into three lessons that are described in detail in each of 31

the following sections. 32

33

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1 First Aid Education Pedagogy in a Unique Context 2

In a community-based first aid program, standard first aid approaches may be neither 3

relevant nor appropriate. Our experience taught us that standard first aid curricula face 4

limitations in a remote, aboriginal community such as Sachigo Lake. To build a first 5

response curriculum for this program, we drew on basic life support and first aid 6

resources from the Heart & Stroke Foundation, American Heart Association and the 7

European Resuscitation Council; wilderness medicine programs from Wilderness 8

Medical Associates International; and emerging mental health first aid materials from the 9

Mental Health Commission of Canada. We discovered quickly, that these conventional 10

first aid resources face two serious limitations for effective capacity building in a remote 11

setting like Sachigo Lake. 12

13

First, these sources often assume an advanced literacy and the cultural and cognitive 14

dominance of the written word among learners. Our participants had a wide range of 15

literacy levels, but few participants learned primarily from text. We identified that these 16

first aid curricula place heavy emphasis on flow charts and acronyms — both of which 17

led to significant challenges for our participants. For example, some conventional first 18

aid curricula use the acronym “AVPU” when assessing a patient’s level of consciousness 19

to represent Awake, responds to Voice, responds to Pain, or Unresponsive. We found 20

through early course simulations that prompting learners to use this acronym as a 21

memory tool was leading to confusion and flustering students. This issue was not 22

specific to one or two students, but a challenge expressed by all students. Assessment 23

of the patient’s level of consciousness was altered to an intuitive approach, requiring 24

participants to identify if the patient was behaving normally, abnormally, or unresponsive, 25

and to identify if the level of consciousness was improving or worsening. Through 26

consultation, we focused on similar assessment principles but phased acronyms out of 27

Box 2. Lessons Learned

Standard algorithmic approaches may not be relevant nor appropriate.

Relationships between course participants and the people they help are relevant and important.

Curriculum must be attentive to existing informal and formal emergency response systems.

1

2

3


the curriculum as they were found to be a stumbling block, rather than a helpful cognitive 1

aid. 2

3

Second, conventional curricula also emphasize pathophysiology, requiring trainees to 4

develop health and physiology literacy in order to understand and provide emergency 5

care. For example, Heart & Stroke Foundation resources on stroke and myocardial 6

infarction are laden with graphics about atherosclerosis and thrombosis. While these 7

pathophysiological teachings serve some learners well, we also observed how this 8

approach could distract participants from the essential steps involved in responding to a 9

family member with signs of stroke or chest pain. Our program did not treat 10

pathophysiological knowledge as a pre-requisite for problem solving and decision-11

making. Pathophysiology was addressed in our curriculum when questions arose from 12

participants. Participants were not taught to identify symptoms of a myocardial infarction 13

in order to make first response decisions because this would require an unnecessary 14

cognitive link between symptoms, pathophysiology, and first response decision-making. 15

Instead, participants were taught a generalized approach to patients complaining of 16

chest pain, requiring only a link between observed symptoms and behaviours, and first 17

response actions. Our approach focused on symptom recognition, critical decision-18

making, safety, and treatment. 19

20

Third, we found both conventional and wilderness first response algorithms contextually 21

and geographically inappropriate. Seemingly universal instructions like ‘call 911’, ‘wait 22

for the ambulance’ or ‘go to your nearest emergency department’ appear throughout 23

commonly available first aid programs. This provides incomplete or inappropriate 24

training to first responders who provide care over extended periods in settings without 25

ambulances or formalized dispatch services. 26

27

In Sachigo Lake, where there is no paramedical nor 911 services, using conventional 28

urban first aid materials re-emphasized service inequities without providing meaningful 29

training alternatives. Our program focused not on when to call for help, nor on protocols, 30

but on relying on oneself and each other to identify a problem, think critically about the 31

situation, and to initiate an appropriate treatment based on the situation. A significant 32

amount of time was spent discussing which patients needed to be transported to the 33

nursing station, how, how quickly, and by whom. While similar principles are taught in 34


conventional first aid courses, the emphasis is on the fact that there is a professional 1

coming to help in an emergency. This is not the case in remote communities such as 2

Sachigo Lake. 3

4

Conversely, wilderness medicine curricula offer an emphasis on remote settings and 5

delays in accessing professional care, but this approach implies a specific notion of 6

‘wilderness’ that may alienate an indigenous community from their traditional 7

environment and way of life. Further, wilderness medicine curricula often are designed 8

for the person who occasionally travels in a remote context. Our program participants 9

articulated a sense of home, safety, and comfort in remote parts of the boreal forest, 10

which was incongruous with discourses and imagery of intrepid adventurers and rescue 11

helicopters that dominate wilderness medicine approaches. Helicopters do not have the 12

range to reach Sachigo Lake First Nation. As such, to reach the Nursing Station or an 13

aircraft, patients are transported by a combination of snow machine, ATV, boat or truck, 14

depending on location and season. 15

In Sachigo Lake, presenting wilderness medicine materials might inappropriately 16

convey that our participants’ traditional way of life is inherently or unacceptably 17

dangerous. For example, it is common for members of Sachigo Lake to travel alone or 18

in small groups to hunt and fish in the region surrounding the community. While this 19

might represent a health or safety risk to outsiders, locals in Sachigo Lake understand 20

traveling in their local region and wilderness surroundings as a safe and normal activity. 21

As part of the program curriculum, simulations were based on this context. During 22

simulations, participants had only the materials and resources that they would have with 23

them while traveling by snow machine or boat, such as a tarpaulin, a gun, an axe, a 24

sleeping bag, rope, tape, food, water, and an extra set of clothes. To manage mock 25

patients, they were instructed to use the materials and equipment they would carry 26

routinely to stabilize, treat, and transport patients to the nursing station in their 27

community. Significant periods of time were spent debriefing simulations, discussing 28

ways to improvise splints, bandages, or transportation packages. Our curriculum offered 29

approaches to emergency management suited for extended patient care in remote 30

settings. 31

32

Developing a community-based first aid program with a remote First Nations community 33

highlights subtle conflicts between the culture of first aid and the context in which it was 34


being taught. Neither conventional urban programs nor alternative wilderness first 1

response curricula offer training that is particularly well suited to an isolated, aboriginal 2

community like Sachigo Lake First Nation. Delivering community-based first response 3

curricula may reveal similar geographical or cultural themes in other unique settings. 4

5

First Aid Delivery in a Small Close-Knit Community 6

Community-based first aid programs must consider the relationships between course 7

participants and the people they may help. Conventional structured approaches to 8

teaching first response, whether designed for the general public or for professional 9

rescuers, are developed under the assumption that the majority of responses involve 10

patients who are strangers. ‘You are walking along the street and you suddenly come 11

across an elderly man who has collapsed....’, and so the scenario plays out. This 12

“stranger assumption” in standard first aid education, where the victim is identified as an 13

anonymous individual identifiable only by their pathology or clinical problem is 14

incongruous in a tightly-knit community such as Sachigo Lake, where everyone is a 15

friend or a family member. 16

17

The stranger assumption in standard first aid creates barriers in a remote community by 18

disregarding existing well-developed relationships. Course participants in Sachigo Lake 19

approached first aid role-play scenarios not as an individual within a community of 20

strangers, but within a network of existing interwoven relationships. Our community-21

based first aid education program adapted to meet the needs in a community where 22

everyone is a friend or family member. Patients had names, rescuers were related, first 23

response necessarily involved close friends. These relationships weare important 24

community resources. For example, during training exercises, relationships and 25

personal connections to the patient were mentioned frequently and were treated as an 26

asset in the provision of personalized, appropriate, and holistic care. Conventional 27

medical and professional models might identify these relationships as a liability, conflict, 28

or problematic barrier to dispassionate decision-making. In Sachigo Lake, we sought to 29

use these relationships as an asset, to involve close family members from within the 30

community as a health resource, and to build community resilience by strengthening the 31

health capacity of families rather than addressing community needs exclusively through 32

access to health professionals. 33

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As part of the 2012 course, we added a module on mental health curriculum that 1

focused on three key areas: thoughts of suicide or self-harm, substance misuse and 2

intoxication, and disorganized behaviour. These themes were identified by the 3

community as priority topics based on their shared experience and previous incidents. 4

Mental health and substance abuse issues disproportionately impact aboriginal 5

population compared to the rest of Canadian population. Suicide is one of the largest 6

contributors to premature death on reserve in Canada, with aboriginal populations 7

suffering three times the potential life years lost due to intentional injury compared to the 8

general population [11]. There were several suicide attempts in 2011 in Sachigo Lake, 9

all among young people. All were non-fatal. Similarly, substance abuse is a major issue 10

in the region, with some remote communities reporting a narcotic addiction rate of 70% 11

among their adult population [12]. In a survey investigating the severity of substance 12

misuse problems as reported by Aboriginal Canadians, 83% of locally elected leaders 13

reported alcohol and illegal drugs as problems in their community [13]. When a 14

layperson provides first aid to a stranger, one would rarely encounter someone who 15

would disclose their suicidal thoughts. Our needs assessment and evaluation identified 16

that although mental health first aid is rarely considered part of a conventional life-saving 17

first response program, mental health emergency skills were as important to local 18

responders as trauma management or cardiopulmonary resuscitation. In this small, 19

remote aboriginal community, where everyone is a family member or close friend, the 20

mental health curriculum was central to meeting community needs and building local 21

capacity to manage emergencies in a holistic and realistic fashion. 22

23

Language and curricula need to embrace established relationships for a community-24

based course to connect with community priorities and to reflect the community in which 25

they live. We believe that community-based first aid programs can enhance community 26

capacity by adapting curriculum to recognize these existing and important relationships. 27

28

Formal and Informal Systems 29

Community-based first aid education must be attentive to existing informal and formal 30

emergency response systems. Conventional first aid training is intrinsically reliant on the 31

existence of an identifiable transition point between bystander first aid providers and a 32

formal health care system. Red Cross or American Heart Association Guidelines, for 33

example, assume that first aid providers will intersect with a formal system of 34


professional providers outside the hospital. In many Canadian communities, informal 1

emergency response involves a bystander performing a varying level of first aid, and 2

using a telephone to dial 911 dispatch services. Once dispatch services are contacted, 3

a formal system is activated, and a patient’s care will flow from paramedical to hospital 4

care. In settings where emergencies are not addressed in this manner, developing local 5

capacity requires that planners understand how a community responds to an emergency 6

to be able to enhance systems without supplanting, bypassing, or ignoring them. 7

8

In Sachigo Lake, there is no formal dispatch or paramedical services. The activation of 9

formal emergency services begins when the patient arrives at the nursing station. All 10

pre-nursing station care is provided through an informal system. Trying to understand 11

this informal system has been part of the collaboration. In Sachigo Lake, this informal 12

system is complex, situational, seasonal, adaptive, and well understood by community 13

leaders. Our observation is that, in many cases, it is also extremely effective. Patients 14

requiring urgent care often receive treatment and transport to the nursing station within 15

minutes. In many cases, nearly the entire community responds to an emergency. 16

Hence, nearly all available resources are present. 17

18

During course development and delivery in Sachigo Lake, curriculum and simulations 19

allowed participants to activate and enhance both formal and informal response 20

systems. Just as course delivery was unique because everyone on course was a friend 21

or family member, so too has it was also distinct because of a shared experience of an 22

informal emergency response system. 23

24

In a final large simulation on course, community members responded to a mock plane 25

crash where four patients had been critically injured. This simulation was based on a 26

previous aircraft crash in the community, and other similar incidents in the region. 27

Participants responded to the incident, stabilized, packaged, and transported the four 28

patients to the Nursing Station where two nurses on-duty received the patients. This 29

simulation integrated an informal pre-nursing station response system with professional 30

nursing care, and it was seen as a success by course participants, local government, 31

nursing staff, and course instructors. This simulation represented a unique intersection 32

of community-based methods and first aid education where the conventional interface 33

between layperson and professional emergency systems were modified to meet the 34


needs in this remote community. Understanding how individuals in a community 1

respond informally to an emergency, is a latent strength in the community that can be 2

reinforced through adaptive curricula. Other communities may have similar informal 3

response systems that can be enhanced through a similar approach to community-4

based first aid. Community-based first response training initiatives must be mindful of 5

these informal systems, and find ways to enhance, rather than supplant or undermine 6

them. 7

8

Conclusions 9

Conventional first aid education relies on the notion that protocols and approaches to 10

managing emergencies are universal across all settings. In a remote aboriginal 11

community in northern Canada with no paramedical services, such algorithmic 12

approaches to first response were inappropriate. Our collaborative approach to 13

community-based first aid, revealed three lessons that we hold central to building 14

capacity in a remote community through the development of an education program. 15

They stand in contrast to principles of “standard” and “universal” first aid that have 16

previously dominated this field. Our observations may be instructive for the 17

development of other programs in similar settings. 18

19

20

21

22

23

24

Acknowledgements 25

We would like to acknowledge the SLWEREI course participants, and community 26

leaders and Elders in Sachigo Lake for their support and insight that helped the team 27

learn the lessons shared in this paper. We also acknowledge Karen Born, Jeffrey 28

Curran, Baijayanta Mukhopadhyay, Calen Sacevich, and Mike Webster for their role in 29

this research collaboration. 30

31

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13. Health Canada. Evaluation strategies in Aboriginal substance abuse programs: A 38 discussion. Ottawa : Health Canada, 1998. Available: http://www.hc-39 sc.gc.ca/fniah-spnia/pubs/substan/_ads/1998_rpt-nnadap-pnlaada/index-40 eng.php#a3_3_2_1_2 (Accessed 17 June 2013). 41

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